0920-22AU Application for Permit to Import Dog Inadequately Immuni

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APPLICATION FOR A PERMIT TO IMPORT
A DOG INADEQUATELY IMMUNIZED AGAINST RABIES

FORM APPROVED
OMB NO. 0920-0134
EXP DATE 03/31/2022

Guidance for completing this application is available at: www.cdc.gov/importation/forms.html.
To Submit Electronically via Email Attachment
• This application is optimized for a desktop/laptop
experience
• If not using Adobe Acrobat®, download Acrobat Reader
for free
• If on a mobile device, download Acrobat® Reader app
from iTunes, Google Play, etc.
• Complete application then save to device
• Email attachment to: [email protected]

To Submit Electronically via Fax
• Print completed application and send to
the following fax number:
404-472-8552

To Submit via Postal Mail
• Print completed application and send via mail
to the following address:
Centers for Disease Control and Prevention
Quarantine and Border Health Services
Branch Zoonoses Team, 1600 Clifton Rd NE,
MS E-28 Atlanta, GA 30329-4027

SECTION A - APPLICANT
1. *Last Name:

2. *First Name:

4. *Mailing Address (Must be a U.S. Address; no P.O. Boxes):

5. *City:

6. *State:

7. *Zip Code (5 digits only):

10. Passport:/U.S. Driver’s License # (choose one):

8. *Phone:

3. Middle Initial:

9. *E-mail:

11. Passport:/U.S. Driver’s License # Issued by:

Passport #:

Country:

U.S. Driver’s License

State:

Clear Choice

SECTION B - PERMIT HOLDER (if different from above)
12. Last Name:

13. First Name:

15. Mailing Address (Must be a U.S. Address; no P.O. Boxes):

16. City:

17. State:

18. Zip Code(5 digits only):

21. Passport:/U.S. Driver’s License # (choose one):

19. Phone:

14. Middle Initial:

20. E-mail:

22. Passport:/U.S. Driver’s License # Issued by:

Passport #:

Country:

U.S. Driver’s License #

State:

Clear Choice

SECTION C - IDENTIFICATION OF DOG
23. *Country of Origin:

25. *Date of Birth

26. *Sex:

(mm/dd/yy)

29. Microchip # (if available):

24. *Length of time (in months) in country of origin:

27. *Breed:

28. *Color (attach photograph):

If other, specify:

Email a color photograph of the dog to [email protected] after
submitting your application.
Reference the Applicant’s name and contact information

30. Tattoo # (if available):

31. Date of rabies vaccination - submit copy of vaccination certificate:
(mm/dd/yy)

*Required field

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer,
1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA 0920-0134.

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SECTION D - ENTRY AND FINAL DESTINATION
32. *Date of entry for intended importation into
the United States:

33. *U.S. port of entry for intended importation

(mm/dd/yy)

Intended Final Destination (i.e., Proposed Confinement Location):
(Refer To The Box Above Section G For Information About Confinement)
34. *Street Address:

35. *Phone:

36. *City:

37. *State:

38. *Zip Code (5 digits only):

SECTION E - TRAVEL INTINERARY
(Complete only one subsection below)
39. *Air
Airline:
If other, specify:

*Transport Entry Method (choose one below)
Hand carry

Clear Choice

Checked baggage

Flight #:
AWB #:

Cargo

40. *Land border crossing

Clear Choice

Private vehicle license plate #:

Bus Company:

State:

Train Company:

Province:
41. *Sea

Clear Choice

Ship company/Vessel name:
If other, specify:

SECTION F - REQUEST DETAILS
42. *Purpose for which the dog is being imported:
Resale

Rescue/Adoption

Personal Pet

Research

Veterinary Care

Other

43. *The reason why permission to import is being requested:
Unable to vaccinate against rabies because of research protocols (attach protocols and other supporting documents)
Dog too young to be vaccinated (i.e., younger than 3 months old)
Less than 30 days after intitial rabies vaccination
Current rabies vaccine certificate has expired
High-risk restricted country approval
Other:

SECTION G - SIGNATURE
I am the owner (or authorized agent for the owner) of the dog listed on this form. I understand that ownership of the dog cannot be transferred to another
person while in confinement. The dog must be confined at the address listed on this form and may not be placed at any other location or with any other person
until the confinement period has ended.
I certify that the information given in this application is complete and true to the best of my knowledge.
I agree to obey the conditions listed in this application. I will comply with all restrictions and precautions in the permit, as well as all applicable import
regulations.
I understand that I may be convicted of a crime if I don’t comply with these import requirements. I could be sentenced to 1 year in jail and/ or a maximum fine
of $100,000 if the violation doesn’t result in a death or a maximum fine of $250,000 if the violation does result in a death. Violations by an organization are
punishable by a maximum fine of $200,000 per violation (if no death) and $500,000 per violation if there is a death. These penalties are provided for under 42
U.S.C. § 264 and 42 U.S.C. § 271 (as enhanced by 18 U.S.C. §§3559 & 3571).

*I understand that checking this box constitutes a legal signature confirming that I acknowledge
and agree to the above Terms of Acceptance.
45. *Date Signed:

44. *Legal Signature: Typed First, Middle Initial and Last Name:

(mm/dd/yy)
CDC Rev. 04-2019 CS303816

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